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A Five- Year Program 

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Committee on the 

Grading of Nursing Schools 



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with the C«npHffient8 of the Connittec 



A FIVE-YEAR PROGRAM 
^ FOR THE COMMITTEE ON THE 
GRADING OF NURSING 
SCHOOLS 



Plan and Budget Submitted by 
MAY AYRES BURGESS, Director 



V 



Adopted by the Committee November 18, 1926 
370 Seventh Avenue, New York City 



No. 6. Price Twenty-five Cents 



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^ A FIVE-YEAR PROGRAM 

^ FOR THE COMMITTEE ON THE '^^f 



GRADING OF NURSING 
SCHOOLS 



o, .^ 



Plan and Budget Submitted by 
MAY AYRES BURGESS, Director 



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Adopted by the Committee November 18, 1926 
yS 370 Seventh Avenue, New York City 



Note: This manuscript was submitted by Dr. 
Burgess to the members of the Committee on the 
Grading of Nursing Schools, and after long and care- 
ful discussion was adopted by them as the official 
program. As soon as this action had been taken, 
the Committee voted that the program be printed, and 
sold at cost, to any interested purchaser. The Com- 
mittee holds itself free to make changes in these plans 
whenever they seem desirable; but if important 
changes of policy are made, they will be given full 
publicity. The Committee plans to keep its cards on 
the table, face up. 



1^6 2.^n.s Ca3 



COMMITTEE ON THE GRADING OF NURSING 

SCHOOLS 

William Darrach, M.D., Chairman, 437 West 59th Street, N. Y. City 
May Ayres Burgess, Ph.D., Director, 370 Seventh Avenue, N. Y. City 
JaaetM. Oeister, R. N., Nurse CoDSuItast 

MEMBERS 

The National League of Nursing Education: 

Elizabeth C. Burgess, R.N., Assistant Professor of Nursing Education, 
Teachers College, Columbia University, 525 West 120th Street, New 
York City. 

Laura R. Logan, R.N., Dean, Illinois Training School for Nurses, 509 
South Honore Street, Chicago, Illinois. 

The American Nurses* Association: 

Helen Wood, R.N., Director, Rochester University School of Nursing, 
Crittenden Boulevard, Rochester, N. Y. 

Susan Francis, R.N., Superintendent, the Children's Hospital of Philadel- 
phia, 18th and Bainbridge Streets, Philadelphia, Pa. 

The National Organization for Public Health Nursing : 

Katharine Tucker, R.N., General Director ^ Visiting Nurse Society, 

1340 Lombard Street, Philadelphia, Pa. 
Gertrude E. Hodgman, R.N., Assistant Professor, School of Nursing, 

Yale University, 62 Park Street, New Haven, Conn. 

The American Medical Association: 

William Darrach, M.D., Dean, College of Physicians and Surgeons, 
Columbia University, 437 West 59th Street, New York City. 

Winford H. Smith, M.D. (Alternate), Director, The Johns Hopkins 
Hospital, Baltimore, Md. 

The American College of Surgeons : 

Malcolm T. MacEachern, M.D., Associate Director, American College of 

Surgeons, 40 East Erie Street, Chicago, 111. 
Allan Craig, M.D. (Alternate), Associate Director, American College of 

Surgeons, 40 East Erie Street, Chicago, 111. 
The American Hospital Association : 

Joseph B. Howland, M.D., Superintendent, Peter Bent Brigham Hospital, 

721 Huntington Avenue, Boston 17, Mass. 
William H. Walsh, M.D. (Alternate), Executive Secretary, American 

Hospital Association, 18 East Division Street, Chicago, 111. 
The American Public Health Association : 

Charles-Edward A. Winslow, D.P.H., Professor, Public Health, Yale 

University, New Haven, Conn. 
Lee K. Frankel, Ph.D. (Alternate), Vice-President, Metropolitan Life 

Insurance Co., 1 Madison Avenue, New York City. 
Members at Large: 

Mrs. Chester C. Bolton, Representing the Patient and the Hospital 

Trustee, Franchester Place, Richmond Road, South Euclid, Ohio. 
Henry Suzzallo, Ph.D., Formerly President, University of Washington, 

Box 641, University Station, Seattle, Wash. 
Samuel P. Capen, Ph.D., Chancellor, University of Buffalo, Buffalo, 

New York. 
Edward A. Fitzpatrick, Ph.D., Dean, Graduate School, Marquette 

University, 115 Grand Avenue, Milwaukee, Wis. 
W. W. Charters, Ph.D., Professor of Education, University of Chicago, 

Chicago, 111. 
Nathan B. Van Etten, M.D., General Practitioner, 300 East Tremont 

Avenue, New York. 



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FOREWORD 

The future of the nurse is of interest to others than the nurse 
herself. For many years the problems of her education, her 
economic condition, her field of endeavor, her relations to the 
doctor, the hospital, the individual patient and the public at 
large have been studied by individuals or committees repre- 
senting the different groups of interested people. It became more 
and more evident that wider and more rapid progress in the 
solution of these problems might be made by cooperative effort. 

With this idea in mind, the American Medical Association 
appointed a committee whose duty it was to confer with repre- 
sentatives of the National League of Nursing Education, which 
had for some time been working on the problem, to devise a com- 
bined method of attack. As the result, a conference was held of 
the representatives of the various national organizations and a 
plan of action agreed upon. This plan was to form a commission 
or a committee made up of official representatives of these vari- 
ous associations interested in nursing, who as a group should 
make an intensive study of the whole problem. Such a commit- 
tee was then formed by each of the following national organiza- 
tions appointing their official representatives : 

1. The National League of Nursing Education. 

2. The American Nurses' Association. 

3. The National Organization for Public Health Nursing. 

4. The American Medical Association. 

5. The American College of Surgeons. 

6. The American Hospital Association. 

7. The American Public Health Association. 

These representatives have added to their number six members 
at large representing the fields of general education, the public, 
and the general practitioner. 

At the first meeting of the Committee on the Grading of 
Nursing Schools it became evident that if the grading was to be 
done wisely and fairly it should be based on the knowledge of 
how the different schools were educating their nurses. This in 
turn required a knowledge of what a nurse should know in order 
to practice her profession. To determine this it seemed neces- 
sary to understand just what the public needed and demanded 
in the way of nursing service. Therefore, the Committee realized 

5 



that if they were to grade efficiently they must first assemble a 
good deal of information which did not seem available. Most of 
the individual members of the Committee had definite opinions 
but were unable to produce much tangible evidence or detailed 
information. 

In studying such a complex problem, no matter how fre- 
quently a Committee made up of active, busy individuals may 
meet, progress will be very slow unless they avail themselves of 
the services of a staff who are devoting all their energies to that 
one problem. It was decided, therefore, to appoint an Executive 
Secretary or Director who should be enabled to assemble a staff 
of individuals properly trained to carry on such investigative 
work. It was felt that the qualifications for such a position 
should be training and knowledge in the field of investigative 
work rather than a specific experience in either medicine, hos- 
pital administration or nursing. It was believed that in this 
way a more unprejudiced attack on the problem could be made. 

The object of such a composite Committee should be to make 
a careful, detailed, unbiased study of the situation and then to 
make a definite recommendation in order that the various parent 
organizations might take whatever action they deemed best in 
the light of such information. The Committee itself should have 
no directing or punitive function. 

A definite plan of attack has been carefully worked out and 
adopted by the Committee and is here presented as a formal five- 
year program. The various steps outlined may have to be 
amended as the work proceeds, and the Committee should be free 
to re-arrange the work as experience may prove wise. Whenever 
results warrant, they should be published and presented to the 
parent organizations and others interested in this subject. 

A satisfactory solution of such an intricate problem can only 
be reached by the patient cooperative effort of all those con- 
cerned, each group trying, with trustful confidence, to under- 
stand the peculiar needs, difficulties, and opportunities of the 
other. 

William Darrach, M.D. 

Chairman 



CONTENTS 

Page 

Membership of Committee 3 

Foreword by the Chairman 5 

Quality, Quantity, and Cost 9 

A Five -Year Program 11 

Proposed Projects, with Budget and Time Schedule 13 

Project 1 — Supply and Demand 14 

Scope of the First Study 15 

Project 2— Job Analysis 17 

What "Job Analysis" Means 18 

Nursing Schools Unlike Other Vocational Schools 19 

Learning by Doing 20 

Job Analysis of Nursing Education 23 

Six Essential Attributes 25 

Scope of Second Study 28 

Project 3— The Grading of Schools 29 

Proposed Method of Grading 30 

Facts— Not Opinions 30 

The Spiral Cone Plan 32 

Grade by Comparative Rank 32 

Include all Schools 33 

Full but Careful Publicity 33 

Five Years of Grading 33 

To Summarize 34 



n 



A FIVE-YEAR PROGRAM FOR 

THE COMMITTEE ON THE GRADING 

OF NURSING SCHOOLS 

May Ayres Burgess 
Quality, Quantity, and Cost 

The Committee on the Grading of Nursing Schools is the out- 
growth of two distinct movements — one on the part of nurses to 
improve the quaHty of nursing, and the other on the part of 
doctors to increase the quantity. These two interests are not, of 
course, mutually exclusive ; and in any given discussion they will 
both receive consideration ; but by and large it seems fair to say 
that in the years immediately preceding the formation of the 
Committee, nurses had been most interested in problems of qual- 
^ ity and doctors in problems of quantity. 

In the nursing profession there has been a plan for many years 
of making a study and waging a campaign which should result in 
raising the educational standards of schools of nursing. The 
underlying assumption has been that the rank and file of nurses 
are inadequately prepared for their work, and that proper care for 
the patient demands better educational preparation. This belief 
is expressed through a strong tendency toward raising entrance 
requirements; establishing schools of nursing under educational 
direction, and sometimes even allying them with universities; 
revising the curriculum ; developing the teaching and application 
of academic and scientific subjects; improving educational oppor- 
tunities within the ward ; and providing for post-graduate courses. 
The emphasis has been upon quality. 

During the same period in which the nurses have been attempt- 
ing to raise the educational standards of nursing schools, the 
doctors have been actively organizing their own committees on 
nursing education, the chief concern of which has been to devise 
means for increasing the number of nurses. They have believed 

^that it was more important for every patient to have some sort of 
9 



a nurse than for a few patients to have extraordinarily good 
nurses. 

A recent report of the ** Special Committee on the Nurse 
Question " of the Medical Society of the State of New York, reads : 
"In view of the fact that there is an all too apparent need for 
more nurses of the bedside type, our conferences discussed the 
desirability of establishing a course of training particularly suit- 
able for this type, and one which could be provided at com- 
paratively small cost by a number of hospitals unable to conduct 
a Registered Training School of present standards." Many simi- 
lar suggestions have been made for revising and simplifying the 
curriculum, in the hope that lowered standards will increase the 
number of students. The primary concern of the medical group 
has apparently been to increase the supply of nursing, even if the 
academic standards of the schools had to be lowered to do it. 
Their chief emphasis has been upon quantity. 

The Public — less sure and less articulate, but increasingly 
restive — has added a third element to the discussion. It wants 
good nursing and plenty of it, but especially it wants a lowering 
in cost. It wants an ample supply of high grade nursing care, at a 
price which it can afford to pay. 

The Committee on the Grading of Nursing Schools is a co- 
operative body attempting to solve all three problems. It is a 
group of nurses, representing the nursing organizations; of doc- 
tors, representing the medical organizations; a laywoman, rep- 
resenting the public; and educators to give technical advice on 
educational problems. The Committee takes its name of "Grad- 
ing" from the original plan of those who hoped, by grading the 
schools, to raise their educational standards. As the differences 
in emphasis have become clear, however, the Committee has 
interpreted its function broadly. It is interested in quality and 
quantity and costs. It has, therefore, taken its function to be the 
study of ways and means for insuring an ample supply of nursing 
service^ of whatever type and quality is needed for adequate care 
of the patient, at a price within his reach. 

The actual grading of schools, that is, is to rest upon a founda- 
tion of broad and careful study. Even were quality alone con- 
sidered, it would probably be impossible to grade the schools 
wisely without such a background. Grading implies the ultimate 
adoption of certain minimum standards which must be met if the 

10 



• 



school is to harvest crops of graduates properly prepared for 
nursing. It is impossible to decide what these minimum stan- 
dards are until we know what qualities the graduates should have ; 
and we cannot know that until we know what they will be called 
upon to do. So we come back again to the decision already 
reached by the Committee on the Grading of Nursing Schools, 
that grading must be founded upon and accompanied by a careful 
inquiry into the underlying facts of nursing employment. 

A Five- Year Program 

The Committee now faces the difficult task of defining and 
limiting its field. There is hardly a phase of nursing which does 
not have its bearing upon the question. The Committee must 
choose the few most pressing problems, and, since they are press- 
ing, hope by rapid work to present reasonably truthful, complete, 
and helpful answers for immediate use. 

As a basis for discussion, the following pages outline a program 
which could probably be completed in five years, at an approxi- 
mate cost of $200,000, and which it is believed would make a 
significant contribution toward the solution of the more impor- 
tant problems in nursing education. The program is divided into 
three main projects. Each project is carried through the full five- 
year period, but with emphasis shifting from one to the other. 

The first and second years would concentrate on project 1, a 
study of Supply and Demand of Nursing Service (which involves 
the question of the nursing shortage, and problems of quantity, 
quality, and cost) and end with a monograph report on that pro- 
ject. The third and fourth years would follow up on project 1, 
but concentrate on project 2, a Job Analysis of Nursing and Nurse 
Teaching (a study, that is, of how nurses are or should be pre- 
pared for nursing service), and end with a monograph report on 
project 2. Project 3, the actual Grading of Nursing Schools, 
would receive steady attention throughout the first four years, 
but would become the chief activity of the fifth year, and would in 
its turn result in a monograph report. It is believed that this 
plan of taking up one project at a time, carrying it through 
swiftly to completion, and formulating the results in a printed 
monograph before concentrating upon the next project, is an 
economical and effective procedure for the small office. 

11 



In discussing the three projects which follow, it should be borne 
in mind that the first outline of any plan is always broader than 
can be carried out in practice. The general field must be marked 
off in advance. As the plan begins to take detailed form, it 
changes from the general to the particular, and the work is con- 
centrated upon a few fundamental operations. The projects as 
now suggested for the Grading Committee are so broad in scope 
as to furnish ample activity for a large and well endowed insti- 
tution, over a period of many years. It is understood that if the 
general plan of campaign is approved, the actual operations must 
be defined and limited to reasonably handleable units. What 
these actual units should be is not worked out in advance, but 
must be discovered as the work is in progress. This is true of all 
plans for research. The preliminary outline is, and must be, 
broader in its implications than the procedures finally adopted. 

For the purposes of discussion and budget planning, the three 
projects have been thought of as covering a five-year period. This 
time allotment, however, should not be considered a definite 
commitment. It seems at the beginning a reasonable guess, but 
as work progresses it may be found that certain parts can be 
carried through more quickly, or certain others will take more 
time, than has been suggested. If funds can be raised to carry 
the work for five years it seems reasonably probable that the 
studies outlined here can be carried to a satisfactory conclusion. 
If, however, the task proves less time consuming than is now 
thought, or if it is found that parts of the work now planned for 
successive stages could be carried on simultaneously, it may be 
possible to shorten the life of the Committee to something under 
the five-year period. 

Similarly, in regard to the methods of study suggested in the 
following pages, it should be remembered that they represent 
only a reasonable hope, not a definite determination. The plan 
offers what seems to be a good experimental approach to the 
problem. If, later, the Committee finds that radical changes are 
needed in its method of attack, it should hold itself free to make 
them. Whatever program is now adopted can at best be only an 
expression of intention. The Committee may hope the plan it 
adopts will prove the right and wise one. It may anticipate no 
radical revisions; but it must not bind itself to any definite 
promise. It must remain experimental in its attitude. 

12 



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Proposed Projects — ^with Budget and Time Schedule 



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Year and 


Project 1 


Project 2 


Project 3 


Total Cost 


Supply and Demand 


Job Analysis 


Grading 


1927 


Study of 7 states. 


Cooperate in Teach- 


Questionnaire on 10 


$33,000 


Returns from nurses, 


ers College study. 


points. All schools. 




doctors, hospitals. 


Include some work 


Rank results. 




patients. Much 


for No. 2 in No. 1 






organization and 


and No. 3. 


Fall, 1927 — publish 




clerical work. 




ranks by states. 




$18,000 


$3,200 


$11,800 


1928 


Finish 7-state study. 


Formulate available 


Make 2d study. In- 


$34,000 


Study local experi- 


data as tentative 


crease data asked 




ments with regis- 


hypotheses. Plan 


for. Write ex- 




tries and hourly 


for next year's 


planatory articles. 




service. Write, 


campaign. 






lecture, formulate 








recommendations. 




Fall, 1928— publish 




Fall, 1928-puUish 




2d rankings. 




monograph. 








$19,000 


$3,200 


$11,800 


1929 


Follow up. 


Field work and 


Make 3d study. Get 


$44,000 




questionnaires on 


some material 






2-way study. 


through work on 






Many conferences. 


project No. 2. 
Fall, 1929-publish 
3d rankings. 




$3,000 


$27,600 


$13,400 


1930 


Follow up. 


Finish statistical 


Make 4th study — on 


$46,000 




studies, make lo- 


broad basis. Cor- 






cal case studies. 


relate closely with 






Formulate philoso- 


project 2. 






phy and recom- 








mendations. 








Fall; 1930— publish 


Fall, 1930— publish 






monograph. 


4th rankings. 




$1,300 


$29,200 


$15,500 


1931 


Follow up. 


Follow up. 


Make 5th intensive 


$43,000 






study. Compare 
with 1st. Formu- 
late recommenda- 
tions and plan for 
future. 

Fall, 1931— publish 
5th rankings and 
monograph. 




$700 


$8,800 


$33,500 


Total costs 








$200,000 


$42,000 


$72,000 


$86,000 



13 



Project 1 — Supply and Demand 

The chief reason why the three great national medical organiza- 
tions were glad to appoint representatives to serve on the Grading 
Committee was because there is great unrest and dissatisfaction in 
the medical profession with the present conditions in nursing. 
This dissatisfaction is expressed in many ways, but it is largely 
founded upon the fact that doctors in many localities are finding 
it impossible to secure a sufficient supply of satisfactory nursing 
service for their patients. The reasons advanced for this shortage 
are varied and numerous, and some of them probably false, but 
the conclusion that there is a shortage of some sort seems un- 
deniable. In the public health field, too, the need for an adequate 
supply of basically educated nurses is becoming increasingly 
pressing. The medical and public health members of the Com- 
mittee are charged with responsibility for studying the situation. 

The nursing members, on the other hand, are aware that 
private duty nursing, where the shortage seems to be most felt, 
is an occupation characterized by serious amounts of unemploy- 
ment. The conditions of employment, moreover, are unsatis- 
factory, and there seems to be a tendency for students to avoid 
entering the field and for nurses who are already in the field to 
leave it rapidly as they find other methods for self-support. The 
nurses, like the doctors, feel an obligation to investigate the 
problem of supply and demand, especially as it relates to private 
duty nursing. 

The question of cost is peculiarly difficult. Full time, day and 
night private nursing service costs from $35 to $112 a week, 
depending on type and place, and length of working day; and 
the average patient finds this charge seriously heavy. The nurses 
who render him this service, however, actually earn surprisingly 
small amounts in the course of the year. Nursing is so seasonal 
an occupation, and even at the height of the season is so badly 
distributed, that large numbers of nurses have annual incomes 
of less than a thousand dollars. This is a powerful factor in 
driving good nurses out of private duty into other positions where 
a regular and reasonably generous pay check every month relieves 
them from the fear of becoming charity cases when they grow too 
old to work. 

A study is now under way in New York State, dealing with the 

14 



economics of private duty nursing. It shows, among other things, 
that half of the private duty nurses in New York State from whom 
answers have been received are either definitely intending to 
leave private duty nursing at the first good opportunity or are 
seriously considering doing so. The three reasons most frequently 
given for wishing to leave the field are : 

Unreasonably long hours 

Inadequate income 

Irregular employment 
The results of the study were presented at the Atlantic City 
meeting of the national nursing organizations in May, 1926. 
They aroused intense interest, and requests are being received 
from all parts of the country for the Grading Committee to extend 
these studies to other states. 

The inquiry into the economics of nursing in New York State 
has been made solely by securing reports from private duty 
nurses. It is believed that not only should similar reports be 
secured from nurses in other parts of the country, and from public 
health and institutional as well as private duty nurses, but that 
at the same time the inquiry should be extended to secure testi- 
mony from doctors, from hospitals, from public health adminis- 
trators, and from patients. Studies based upon the actual experi- 
ence of the doctor are particularly important, since no solution of 
the problem is possible until we know what sorts of nursing service 
he needs for his patients and what difficulties he is actually en- 
countering in securing such service. 

Scope of First Study 
The first project suggested for the Grading Committee's pro- 
gram is to make this study. It would be conducted largely by the 
questionnaire method and would reach private duty, institutional, 
and public health nurses, doctors, public health men, hospitals, 
and patients, in perhaps seven or eight different states. The 
gathering and tabulating of this material would take a little over 
a year. It would yield not only statistical findings of conditions, 
but suggestions as to methods by which they might be remedied. 
The latter part of the second year would, therefore, be spent in 
studying local experiments which seem to point towards a solu- 
tion and in formulating a constructive program in the light of 
those statistical and case studies. The results of the studies and 

15 



the suggestions for remedying conditions found should be incor- 
porated in a small monograph, which should be in the hands of 
the printer before the end of the second year. 

The nature of the recommendations put forward in this mono- 
graph cannot, of course, be predicted with any certainty. If the 
studies already made in New York State are typical, the mono- 
graph, in addition to presenting the facts concerning the em- 
ployment of nurses, would in all likelihood need to take up with 
some care the questions of registries, on the one hand, and hourly 
service and group nursing in hospitals, on the other. 

It may be that one of the most effective ways for providing the 
nursing service needed might be through the establishment of 
central registries of a type practically unknown at present. These 
registries would be under the direction of highly paid, pro- 
fessionally minded nurses. They would be clearing houses for the 
use of nurses, doctors, public health workers, hospitals, and 
patients; but they would be more than that. They would pro- 
vide professional supervision for private duty nurses after grad- 
uation; and they would encourage attendance at clinics and 
institutes, for the improvement of graduate service. They would 
take all the nursing material available and classify it according to 
the types of cases which each group of graduates could properly 
handle. There would be a definite attempt, that is, to provide 
the doctor with the sort of co-worker he wants, to provide the 
patient with the nursing care he needs, and to place the nurse in 
the sort of position where she can do good work and be happy. 
The growth of great professional registries would seem, from the 
New York studies, to be a probable development of the future. 
It remains to be seen whether studies in other parts of the country 
will bear this out. 

The New York State findings have also indicated the possibility 
that the present waste of nursing skill, resulting from keeping a 
nurse idle while on duty, is in part responsible for the high cost, 
and might well be avoided by the use of group nursing in hospitals 
and by substituting hourly service for twelve or twenty-four-hour 
service wherever the patient's needs can adequately be met on 
the hourly basis. Here, again, further study in other states, with 
reports from doctors and hospitals, as well as from nurses, is 
needed before definite conclusions can be drawn. 

Consideration of the possible remedies for the nursing shortage, 

16 



such as reorganized registries, group nursing, hourly nursing, or 
whatever other experiments are indicated by the findings, should 
probably be included in the monograph on supply and demand, 
which would mark the culmination of the first two years of study 
on the part of the Grading Committee. After the report was 
published, the work ought not to be summarily dropped. It 
would arouse, almost inevitably, a large amount of discussion in 
which the Committee would be called upon to participate. As 
with each of the other projects suggested, it would be necessary 
to continue active interest during the entire five-year period. The 
principal piece of research on supply and demand, however, 
should be completed within the first two years. 

Project 2 — Job Analysis 

The project on Supply and Demand is an attempt to study the 
quantity and types of nursing service needed and where they are 
to come from. The second problem is one of quality. What is 
good nursing? Testimony from doctors varies from those who 
say that "the woman of good intelligence who has passed one 
year or even six months in the wards of an active hospital is per- 
fectly qualified to nurse any case of typhoid fever or pneumonia 
that will occur," to those who regard good nursing as often the 
chief element in cure, and who feel that a good nurse is a gift from 
Heaven. Some doctors want handmaidens; some, skilled autom« 
ata; and some, intelligent co-workers. Some say that the nurse 
is a sort of sub-doctor, who can never develop further; others, that 
she is of an entirely different breed, belonging to a distinct pro- 
fession, as does the dietitian or occupational therapist. 

Before the Committee on Grading can proceed to assist schools 
in preparing good nurses, it must discover first, what is good 
nursing, and second, how can it be taught? The method for doing 
this is what is known as "job analysis." This means that we dis- 
cover what a nurse should be like by studying her in action and 
seeing what she has to do. We list what she does, discover what 
problems she faces, and learn what she needs to know in order to 
meet them. When a careful analysis has been made of what the 
nurse needs to know and be, we then proceed to the second, and 
far more difficult process of analyzing the elements in the job of 
teaching her so that she will have these qualities. 

17 



What "Job Analysis" Means 

The so-called "Job Analysis" technique is comparatively new 
in educational administration. It has been used with interesting 
results in studying the education — among others — of private 
secretaries, librarians, apothecaries, and school teachers. In the 
private secretary study, for example, it was felt that if secretarial 
schools were to succeed in giving employers satisfactory secre- 
taries, the schools must first find out what a private secretary is, 
and what she has to do. 

Accordingly, the day by day and hour by hour activities of 
many hundreds of private secretaries, in different types of offices, 
were carefully and minutely listed. The study was made not of 
what the secretary thought she did, but of what she actually did, 
and how often she did it. The study included an analysis of what 
problems the secretary faced, and what she needed to know — or be 
— in order to solve them. 

Finally, this great mass of evidence was sifted and analyzed, to 
discover by what methods the secretarial school could most 
quickly and thoroughly prepare the student so that she could do 
these things and meet these problems effectively. The result of 
this study will apparently be to throw out of the approved cur- 
riculum for secretarial schools much material which students have 
been taught and for which they have had no practical use after 
they left school, and to add to it many elements which have been 
overlooked. 

Job analysis has been of particular value in those fields where 
vocational schools have been founded upon and consequently 
molded by academic tradition. They have been — many of them 
— academic high schools, remodeled by inserting some hours of 
shop or office practice and by copious use of "practical problems" 
and illustrations in the teaching of the formal subjects. In such 
schools there are usually as many hours spent in class as in shop ; 
and there is much formal teaching, by lecture and textbook, of 
material which the student is unable to use after he gets out. 

In schools such as these — and most vocational schools conform 
fairly closely to the type described — an analysis of what the stu- 
dent will actually have to do, and an insistence that non-useful 
academic teaching be curtailed, may be wonderfully salutary. 
The people in charge of the schools are — a large proportion of 
them, anyway — professional educators, steeped in the academic 

18 



I 



tradition, and with only a second-hand acquaintance with the 
occupation for which they are supposed to prepare their students. 
It is essential that they be helped to think in terms of the job to 
be done. 

Nursing Schools— Unlike Other Vocational Schools 

In the education of nurses we have a different situation. It is 
a type of vocational education, probably unlike anything else of 
which we have record. ''Nursing schools," i'n the first place, are 
not schools at all in the sense that most educators use the term. 
This is illustrated by one of the editorials in a recent issue of The 
Modern Hospital, which begins, "Shall we call them Nurses' 
Homes or Schools of Nursing?" and seriously discusses the ques- 
tion, pro and con. If we define ''teacher" as one whose main j oh 
is the instruction of students, there are apparently something like 
600 of the 1500 schools for which we have records — nearly 40 per 
cent, that is — who do not have a single teacher in the entire school. 

Moreover, in the accepted sense, there are practically no 
classes. Students are gathered in groups for certain lectures and 
demonstrations, but most of their time is spent outside the class- 
room. Two recent incidents illustrate this point. The other day 
the writer overheard a conversation between two directors of 
nursing schools — or what public educators would call school 
principals. Each had recently moved into a large and beautiful 
new building. Said one, "You lucky woman, you don't know how 
I envy you!" and turning to the writer she added, "This woman 
has actually two classrooms, which are to be used for nothing 
but teaching!" 

The other incident occurred in one of the best known schools in 
New England. In talking to the Director of Nursing the writer 
asked her, "What, if anything, do the hospital medical staff 
criticize about your school?" Her answer was, "The thing that 
makes most trouble is to have the doctor come into the ward 
and discover that some of the students have gone to class. It 
simply makes him see red!" 

In large numbers of nursing schools it is almost fair to say that, 
in the traditional sense, there are no teachers, no classes, and no 
curricula. Students do go through, in many of the better schools, 
four months of concentrated classroom and textbook work at the 
very beginning of their training; and after that they have lec- 

19 



tures and demonstrations; but most of the three long years of 
student life are spent not in studying how to nurse, but in actual 
nursing. 

Vigorous attempts have been made by nursing leaders to work 
out a standard curriculum and course of study. The fact seems to 
be, however, that the scientific and academic subjects which most 
readily yield to classroom technique, but which in even the 
extremely radical plans occupy only one-tenth of the three years' 
period, are the parts of the curriculum which are most nearly 
adopted. If the school curriculum, that is, calls for forty-five 
hours of bacteriology, there is a reasonably good chance that 
most of the students will get their forty-five hours. But if the 
curriculum calls for 688 hours of experience in pediatric nursing, 
the amounts of such nursing actually secured by students in the 
same school may range from none at all to 2,000 hours. The 
suggested curricula give small amounts of class work, and large 
amounts of different sorts and difficulties of ward experience, but 
in most nursing schools it is only the class work which is standard- 
ized, and the greater part of the curriculum remains a desired, 
but under present conditions apparently unattainable program. 

Another fact which strikes the public educator as strange is that 
there is a remarkably small student body. No one knows exactly 
how many schools there are in this country. There are about 
1,500 for which full details are available in the official nursing 
directory, and probably several hundred other schools exist. Of 
the 1,500 for which we have records something like half have an 
active student body of less than thirty. Many schools, respected 
in their communities, regularly graduate only one or two students 
a year. It is with such little isolated groups as these that we have 
for the most part to deal. 

Moreover, in many schools there is no regular time schedule. 
Students enter whenever they are ready. They work for thirty- 
six months and are through. After the probationary period is 
over, it is frequently true that any girl who obeys rules and works 
hard is practically assured of graduation. 

Learning by Doing 
In spite of the absence of most of those things which the pro- 
fessional educator automatically thinks of when he says "school," 
the fact remains that many of these nursing schools, in so far as 

20 



» training students to care for the sick in their own hospitals is 

concerned, are doing remarkable work. They provide convincing 
proof of the accepted but rarely practiced educational maxim, 
"We learn to do by doing." 

The system is commonly referred to as "apprenticeship," but 
it is not really that. In apprenticeship there is usually a beginner 
assigned to help the skilled workman. It is very nearly a one-to- 
one relationship. We had it in the old days in medicine, when the 
medical student cleaned the doctor's office, ran his errands, helped 
with his cases, and read the doctor's library in his intervals of 
leisure. Similarly, the law student "read law" by attaching him- 
self to the office of some successful lawyer, making himself useful, 
and picking up what he could. 

Nursing, however, has never been Hke that. The student nurse 
does not assist the graduate; she carries the responsibility her- 
self, and instead of having one experienced veteran workman to 
every beginner, there are many schools with only two or three 
graduate nurses on the whole staff. 

The training is not Lancastrian, or monitorial, where particu- 
larly bright students are set to teach their fellows. It seems to 
m consist largely in having a great deal of vitally important work to 

be done, and in dividing it up among the available workers (who 
are all students, of course), in such fashion that the easiest jobs go 
to the least experienced workers and the hardest to the most 
experienced. The workers are given as much preparation for 
what they are to do as time permits — and often this is very careful 
instruction and supervision. If, however, there is great pressure, 
and little time for teaching, the work still has to be done and done 
by the students. No matter how difficult the technique or how 
inadequate the preparation of the students, they must accept the 
responsibility. There is no reserve corps of experts to call upon. 
The students are definitely given life and death responsibility, 
and expected to carry it. 

This is Spartan training. The reason why it works as well as 
it does seems to be that the tasks the students do are real, not 
faked. They are not "preparing to be nurses," they actually are 
nurses; and they learn their "lessons" with extraordinary 
rapidity and thoroughness, because if they don't learn, their 
patients may die. 

Were funds and time available it would probably be well worth 

21 



while to make careful inquiry into the nature of nursing educa- 
tion, even though there were no question of grading, because of 
the contribution such a study might make to the wider field of 
public education. We have here a type of school, different from 
every other, lacking most of the attributes which are ordinarily 
considered essential to effective work, and yet doing, and fre- 
quently doing well, the job for which it was created. If, by study- 
ing what it is that makes the nursing school effective, the Grading 
Committee can throw light upon the essential nature of learning, 
it will make an important contribution to the larger body of 
educational theory. 

We have, then, a series of important contrasts between the 
typical vocational school and the school of nursing. The voca- 
tional school is run by a staff of people hired to teach. They are, 
most of them, professional teachers, with normal school or college 
backgrounds. Their chief interest lies in teaching academic sub- 
jects. They conscientiously try to study the nature of the work 
for which they are preparing their students and to adapt their 
teaching to it. They are not themselves, however, doing that 
work, day by day. They are only teaching it. Moreover, what- 
ever shop or office practice they are able to provide for their stu- 
dents is usually artificially arranged, and carefully adapted to the 
students' needs. It does not, in itself, have to be done. 

The nursing school is run by a staf¥ of people most of whom are 
hired, not to teach, but to nurse, or to supervise and administer 
nursing. Whatever teaching they do must ordinarily be sub- 
ordinated to nursing. There is always more work than can be 
done. The executives work under constant strain, and feel little 
temptation to add extra courses or teach unrelated academic 
material. The heads of the school have had little training in edu- 
cational administration. They have few pedagogic theories. 

Here, in fact, is probably the greatest contrast. The typical 
vocational school thinks a great deal about how to teach, but less 
about what to teach. The nursing school, on the other hand 
(in so far as work in its own hospital is concerned) , knows down 
to minute detail what to teach, but has hardly begun to analyze 
the theory of teaching it. That the teaching for the most part 
succeeds as well as it does is probably due not to any theories the 
schools may have, but to the intense concentrated seriousness with 
which students and superintendents take their work. 

22 



Not all of the schools are equally successful. Many schools are 
connected with small hospitals, where there is not enough nursing 
to be done. If the entire hospital has, on the average, only ten 
patients at a time, the student is not going to meet the variety of 
diseases or learn the number of techniques she needs to know. 
Even a daily average of thirty-five patients is questionably small, 
yet over a quarter of the schools of the country belong to hospitals 
with thirty-five patients or less. 

In the large hospitals there is another sort of danger. Where 
there are large numbers of patients and comparatively few stu- 
dents to do the work, the school superintendent naturally tends to 
adopt efficiency methods. She does what any other adminis- 
trator would do — she divides her jobs into processes and assigns 
one worker to each process. Instead of the old fashioned and 
educationally valuable scheme whereby the student was assigned 
five patients and ordered to take complete care of all five, the busy 
administrator tends to assign one nurse to take all the tempera- 
tures, another to administer all the medicines, a third to carry all 
the trays, and so on. 

This form of organization gets the work done quickly and well. 
It also, however, formalizes the thing. It takes away from the 
student her feeling of responsibility for the individual patient. 
If he gets well, it is not particularly her triumph. If he dies, it is 
not particularly her disaster. The factory method is rarely com- 
plete, of course, but in most of the large and well known schools 
there seems to be enough of it to form a serious educational 
problem. 

Job Analysis of Nursing Education 
Nursing education seems unique. Because it is unlike any of 
the traditional forms of education, it cannot properly be judged 
by the traditional tests of educational efficiency. We must not 
use the traditional school survey, in order to discover whether or 
not a nursing school is doing good work, because the survey tech- 
nique has not been developed for schools of this peculiar type. 
We must work out a new technique, and this must be based upon 
a study of what good nursing service involves, and how it can be 
taught. This leads us to our second project, of job analysis. 

Most job analysis in other vocational fields has placed its 
major emphasis upon trying to discover what was not at all 

23 



commonly known — the details of doing the work. The secondary- 
emphasis has usually been upon analyzing the job of teaching 
them. In the nursing study it seems probable that this emphasis 
should be reversed. The question of what nurses have to do after 
graduation is important; but for private duty nurses at least — 
and they far outnumber all the others — many of its essential 
features are already known. There are huge textbooks full of 
instructions for the actual care of sick patients, in the ward or in 
the operating room, in minute and practical detail. 

What the private duty nurse has to do after she is graduated, 
the specific tasks, that is, which she has to perform, are most of 
them, just about what she has to do while she is still in school. 

There are some extra things she needs — as for example the 
ability to fit into a household, or to devise substitutes for ex- 
pensive hospital equipment, or to give to men patients certain 
treatments which in some hospitals are always given by male 
orderlies. If her hospital has specialized in only a few types of 
work, she may need to supplement her training by experience in 
some other institution. Or if, in the future, society is going to 
demand that all nurses shall have the point of view, the knowl- 
edge of home conditions, the respect for the personality of the 
patient, and the desire to teach as well as to serve, which are now 
characteristic of "the ideal nurse" in the minds of a few far- 
sighted leaders and are particularly emphasized in the field of 
public health nursing, radical changes may perhaps be needed in 
her undergraduate work. Also, if the studies of supply and 
demand indicate any decided changes in the conditions of graduate 
nursing, these should be analyzed to see what preparations should 
be made for meeting them. It seems probable, however, that a 
comparatively simple study of nursing functions will yield as 
much material as can profitably be used by the Grading Com- 
mittee. 

The other part of the job analysis, however, would seem far 
more difficult, and of considerably greater importance. This is the 
analysis of the job of teaching nurses. Here there are as yet few 
textbooks, and little coherent testimony. Yet there is evidence 
that many nurses are improperly or inadequately taught, and 
there is some reason to believe that even the largest and best 
known schools are in danger of failing on important parts of their 
work. 

24 



$ 



Six Essential Attributes 

Good nursing may be thought of as having six important char- 
acteristics. Simplest to teach and to understand is the charac- 
teristic of manual skill. The good nurse has learned how to move 
quietly and gently; how to make beds, and apply bandages, and 
do many other things, some of which call for nice muscular 
co-ordination. 

When the doctor says that he wants a nurse "who knows her 
business and can follow orders," he probably means that he 
wants some one who has learned good techniques for doing things, 
and has practiced them so much that they are matters of habit, 
and she can do them whenever needed, and invariably well. It is 
this physical part of nursing which lends itself most readily to job 
analysis, and which is probably in the minds of most people when 
they talk of "basic nursing" which every nurse must learn. 

The other five characteristics of good nursing are a little less 
easy to describe. Important among them is what the Spaniards 
call the "gift of people" and what, for want of a better word, we 
can call "leadership." It is the thing that enables the nurse to 
lead her patients to believe in the doctor and to take the doctor's 
orders seriously. It is the thing which makes her able to teach 
the patient, so that he learns not only what the doctor wants him 
to do, but why. It is what makes her able to get the patient to 
eat when he is not hungry. It is a characteristic born in or 
acquired by successful politicians, and salesmen, and women of 
"charm," and it is particularly valuable in the case of the nurse. 
It is probably what the doctor means when he speaks of the nurse 
who "knows how to handle people." 

Another quality apparently essential to good nursing is the 
quality of persistence. It is the quality which keeps the Red 
Cross nurse at the scene of disaster, on duty 50, 60, 70 hours at a 
stretch. It is the thing which keeps doctors and nurses at the 
bedside, fighting desperately side by side to save the patient who 
they know cannot be saved — working to perform a miracle. It is 
what the athlete calls "the ability to punish oneself." Probably 
the deep underlying respect and affection between the medical 
and nursing professions, which although often clouded by surface 
irritations and misunderstandings, is nevertheless so impressive 
to the outsider, rests upon the mutual recognition that nurses and 
doctors know how to fight. They carry on. 

25 



A fourth characteristic of good nursing is the knowledge of 
what it is all about. The good nurse is the experienced nurse. 
She has seen and cared for and thought about many different 
sorts of people, with many different sorts of trouble. She has 
read books and talked with doctors and other nurses. She has a 
broad background of information and practice. The superin- 
tendent of a famous metropolitan hospital, handling a wide 
variety of cases, recently remarked, "There is an enormous dif- 
ference between the two-year and the three-year nurse; and so 
far as I can tell the superiority of the three-year product results 
not from the extra classes she may have had, but from the fact 
that she has been given another twelve months of responsible and 
intensive contact with sick people. She is permeated with her 
subject." 

The fifth characteristic is kindness — good heartedness — but of 
a sort which is extremely rare because it is kindness dominated by 
intelligence. It is a viewpoint peculiar to good nurses — what 
Professor E. L. Thorndike of Columbia would call a mind "set" 
for the patient's physical and mental well being. It is the attitude 
of mind which, when her post-operative patient has just dropped 
asleep after having received ^ of a grain of morphine, makes the 
nurse omit the morning bath and let her sleep, instead of forcibly 
shaking her awake again. 

This "set" of the mind upon the well being of the patient is 
illustrated by the story of the private duty nurse who was called 
into an isolated Illinois farmhouse in the dead of winter to a 
scarlet fever case. The child patient was apparently dying of 
exhaustion, because she could not sleep. The mucous membrane 
of nose and throat had become so badly swollen that whenever 
she fell asleep the dried tongue stopped the child's breathing and 
she woke again. 

The nurse, watching the child, discovered the difficulty. 
Wrapped in a blanket, in an unheated bedroom in zero weather, 
she sat all night long at the bedside with a glass of water and a 
medicine dropper, letting fall drop after drop of water upon the 
child's swollen tongue, so that the child slept peacefully all night 
through. That was more than kindness or sympathy. It called 
for endurance, but it also called for insight into what was wrong, 
and ingenuity as to the remedy. This type of mind "set" for 
the patient's physical and mental well being is probably what 

26 



I 



nurses and doctors mean when they speak of ** the art of nursing.'* 
It was described recently as characteristic of ''the nurse who 
knows what to do — when." 

Finally, perhaps the most interesting and dramatic of the 
qualities which make for good nursing is a kind of acute perception 
which gives to some nurses what seems to the outsider an uncanny 
ability to know what is happening to the patient. It is sometimes 
spoken of as "intuition," or the nurse's "sixth sense." It seems 
to be acquired by especially intelligent nurses, as a result of long 
hours of concentrated highly keyed attention to patients. These 
particular nurses become sensitive to extremely slight stimuli, 
such as scarcely perceptible changes in the color of a patient's 
skin, or the odor of the room, or the angle his hand makes with 
his wrist. 

It is this extreme responsiveness to slight stimuli which makes 
possible this story of a ward supervisor in a maternity hospital 
who said, "I've sort of got so I recognize patients who are going 
to need watching. There was one woman — for example — I had 
finished my rounds and was going off duty, but I couldn't get her 
off my mind. I had been in to see her and she seemed all right, 
but I had a hunch she wasn't. So I went back for another look. 
And believe me, one look was enough ! I simply dove under the 
bed clothes and grabbed her!" It was a postpartum hem- 
orrhage. Most good nurses would have recognized such a hem- 
orrhage after it was well started, but only the exceptional nurse, 
peculiarly sensitive to extremely slight stimuli, would recognize 
it at its onset. 

Of these six characteristics, only manual skill is usually directly 
aimed for in training, and yet it is perhaps the least important of 
the series. The others are acquired in varying degrees by the more 
intelligent and experienced nurses, but except in a few schools 
they do not ordinarily come as the result of careful planning; 
they just happen. 

If the Committee is to make a job analysis, it must form a 
judgment as to how important manual skill, leadership, per- 
sistence, knowledge, mind "set," and acute perception are in 
nursing; and it must follow this by a study of training school 
activities — an analysis into the processes by which students be- 
come nurses — in order to discover under what conditions these 
capacities develop. 

27 



It will probably be found more important, for example, that 
nurses should have this insight, viewpoint, and understanding ^fe 

of the patient than that they should have a working knowledge ^'^ 

of how to compound drugs and why. The chemistry is im- 
portant, but the other thing is probably even more important, 
and in recommending changes in the curriculum, to provide for 
the skills, book knowledges, classes, and demonstrations, which 
are obviously needed if the nurse is to do her job well, the Com- 
mittee must be in a position, at the same time, to cherish and 
foster whatever it is in the training school life which cultivates 
these other things which are so close to the "spirit of nursing.'* 

Scope of Second Study 

The study of job analysis, as suggested here, would be con- 
centrated in the third and fourth years of the Committee's 
activity. The two preceding years, while devoted primarily to 
supply and demand, would, nevertheless, have gathered much pre- 
liminary material, so that at the beginning of the third, there would 
be at hand various working hypotheses upon which to proceed. 

The study would involve a detailed inquiry into the activities of 
nurses at work and be supplemented by an extended and careful 
study of the processes of nurse education. Those parts of school 
life which seem to have little actual effect upon the mind and 
spirit of the students would be passed over lightly, but certain 
aspects of school procedures and administration would probably 
need careful attention. 

The project on job analysis would lead first to much discussion 
and thought about the essentials (not the details of curriculum) 
of nursing education. Second, it should give practical help in 
meeting administrative and teaching problems. This help should 
be directed not only to nursing school superintendents and teach- 
ers, but to hospital administrators, medical staffs, and boards of 
trustees, in so far as their duties relate to the nursing school. 
Third, the project might contribute considerable material which 
would be available for short practical courses in training school 
administration. Perhaps one of the chief needs of nursing educa- 
tion today is for better trained superintendents, and anything 
which the Grading Committee could do, of a thoroughly practical 
nature, to help superintendents handle their jobs would seem 
worth working for. 

28 



s. 



It 



At the end of the two-year period it should be possible to pre- 
pare a report, to be published in monograph form, upon the 
results of the study. This report would probably not go into 
details of curriculum. It would, however, endeavor to discuss 
the problems of "What is good nursing?" and "How can the 
schools provide the conditions and experiences which make for 
its favorable development? " It would suggest desirable methods 
for the careful revision of the curriculum by nursing leaders; and 
it would, also, furnish a better basis than any now at hand for 
knowing on what elements the effective work of a school depends 
and, consequently, on what points it should be graded. 



Project 3 — The Grading of Schools 

Many of the people who have been interested in the grading of 
nursing schools have had in mind the effective work in grading 
medical schools and hospitals carried on by the Council on Medi- 
cal Education of the American Medical Association and by the 
American College of Surgeons. The valuable results secured by 
these gradings are probably due, in part at least, to certain char- 
acteristics of the methods employed. In the first place, the stan- 
dards are simple to understand, and sufficiently easy of attain- 
ment so that they are within the reasonable grasp of any institu- 
tion which is willing to work for them. The standards are few in 
number, so that it is possible for the institution to concentrate 
its energies upon an unpretentious program. And, finally, the stan- 
dards are so selected that each is a potential source of strength. 

It is, for example, a relatively easy matter for any hospital to 
have staff conferences. It is probable that in some cases those 
conferences at the beginning were not particularly well adminis- 
tered ; but somehow it is good for people to get together to talk 
over their work, and there is something about the very act of 
doing so which sets people thinking. The staff conference even 
when adopted as a formality in order to secure a better rating, has, 
time after time, become an essential part of hospital procedure. 
Similarly, with the other items which were chosen for grading by 
the two organizations. Any one of them might, at the beginning, 
be less effective than what was intended, but once adopted, there 
was good chance that it would grow in value. 

29 



Proposed Method of Grading 
The grading plan which is tentatively proposed for the Com- ^g 

mittee on the Grading of Nursing Schools would have similar 
characteristics. It would start with simple standards, easy of 
attainment, and few in number, and, in so far as possible, each 
standard would be potentially valuable. It is suggested, however, 
that, since what is wanted is not so much the actual marking of 
the schools as it is the stimulating of schools to do increasingly 
better work and to think with increasing interest and clearness 
about nursing education, a single grading would be less effective 
than some regularly repeated method of reaching all the schools 
every year, so that no good school would feel that it could rest 
upon its laurels and no poor school would feel that its one chance 
to redeem its name had gone forever. 



Facts— Not Opinions 

The data on which the schools are graded should be matters of 
fact, instead of opinion. This is a practical necessity. The reason 
is that questions of fact can be verified. They are not open to 
argument, because they will appear the same to each observer. 
If, for example, the school is graded upon the educational prepara- 
tion of its teachers, the question is one of fact. Two years of high 
school or no high school at all are facts which can be verified. If, 
on the other hand, the question concerns the influence of the 
teacher on the students, it at once becomes a matter of opinion, 
and in case of disagreement, there is no way in which the Grading 
Committee can prove that the opinion of its investigator is 
superior to the opinion of the director of the school. 

Moreover, it is desired to grade every school once a year for 
five years, since five gradings, at yearly intervals, will be far more 
effective than one. There are probably about 2,300 schools to be 
graded each year. To make an individual visit, thorough enough 
to serve for so serious a thing as the grading of a school on the 
basis of opinion, takes time. Assuming two days for each case, which 
is probably much too small an allowance, it would require a force 
of 20 or more workers, full time in the field, to make the rounds. 

These visitors would have to be of much finer calibre than the 
ordinary field worker. If the schools feel that their professional 
future rests upon the unsupported opinion of a woman who spends 

30 



« 



€ 



i 



only two days studying them, they will require proof that she is 
competent. In talking with hospital people about gradings which 
have been made on the basis of visits by field visitors, one is im- 
pressed with the concentrated venom sometimes evoked by the 
memory of the unfortunate visitors. One director of a famous 
hospital, for example, reported how "The young whipper snapper 
comes into my office and assumes that he knows more about my 
business than I do." Part of the irritation against state examiners 
of nursing schools is expressed by "What made her think she 
knew enough to judge us?" Wherever field workers are charged 
with inspection they run the danger of arousing antagonism, even 
though their observations may be accurate, and their judgments 
fair and wise. 

If the aim of grading is to arouse enthusiastic cooperation, it 
would seem wise to be cautious about the use of visitors; and 
where some visitation seems unavoidable and where it must deal 
with questions of opinion, to secure nationally known women to 
do it. Judgments made by visitors whom the victims acknowl- 
edge as of higher professional standing than themselves, will 
ordinarily be accepted with fair grace. The work of the school 
surveyor is of great importance, and has great possibilities of 
helpfulness. For purposes of grading, however, it seems the part 
of wisdom to base comparative ranks upon items of definitely 
ascertainable fact, which can be verified without expert assistance, 
and can be reported to the Grading Committee either by the 
schools themselves or by local or state authorities. 

Whether it will be possible to rely entirely upon the question- 
naire method in securing data for ranking depends first upon the 
skill with which the questionnaire is devised, and second upon 
the intelligence and experience of the training school people who 
are asked to fill it out. It is rather likely that for at least part 
of the work it will be found necessary to employ representatives 
to go to the schools not to make inspections, but to explain what 
is wanted on the questionnaire, and to assist the head of the 
training school in deciding on the correct answers. This work 
might be done by nurses on the staff of the Grading Committee, or 
by local nurses who could be secured on a temporary basis to assist 
the Committee for this purpose within their own states. The cost 
of such additional local service is difficult to predict until some 
experiments have been made. In the proposed budget it has been 

31 



estimated as $5,000 each year, or a total of $25,000. This is in- 
cluded as part of the sum under the item of ** field workers." 

The Spiral Cone Plan 
It is suggested, then, that the schools be graded once a year for 
five years, and that the grading scheme be something like an 
inverted spiral cone. Starting at the bottom, the first year, the 
grading would be on a very few points, and easily within reach. 
The next year there would be more points, and they would be 
slightly more difficult. The third year the standards would again 
be raised and their number increased, and so on, working spirally 
upwards and outwards as it is found that the schools are them- 
selves lifting and broadening. It is believed that the spiral cone 
plan is the most painless and effective method for raising the 
average standing of schools. 

Grade by Comparative Rank 

It is suggested that the grades be given not in terms of so many 
per cent or of arbitrary a, b, c, and the like, but that, rather, a 
school's standing be stated in terms of how it compares with 
other schools. It would proba'jly be more significant to a board 
of trustees to learn that nine-tenths of the schools in the country 
have a shorter working week than they do, than it would to learn 
that on length of working week their school is marked " D." The 
board of trustees probably does not much care what a group of 
people, sitting at their desks in New York, think about its work- 
ing week. It would, however, probably react most vigorously to 
the discovery that it has a worse record than any other school 
in the state. The competitive instinct is a powerful lever for 
improving conditions. It would seem good policy to utilize it by 
adopting the ranking method for grading. 

Moreover, if ranks are used — if, that is, grades are always 
stated in terms of how the school compares with other schools — 
and if the process is repeated from year to year, there need be no 
arbitrary statement of perfection. There is no need to define a 
"Grade A" school. The average school this year may have a 
fifty-six hour week, but next year the average may have dropped 
to fifty- two. A school which wants always to be above the average 
must continue to do better, all the time. As conditions improve in 
some of the schools, the ranking method automatically raises the 

32 



standards for all the others without any arguments from head- 
quarters. 

Include All Schools 
It is suggested that the grading include as many schools as 
possible. There are probably about 2,300 schools in the country, 
and while at first many of them may be hesitant about joining, 
it should eventually be possible to secure returns from al- 
most all. It takes very little more work to reach most of the 
schools than only a few, and the results are far more significant. 
If the precedent can be established that every school, as a matter 
of course, answers the questionnaires of the Grading Committee, 
the influence of the Committee will be enormous — far beyond 
anything which could result from grading, say, two or three hun- 
dred of the most cooperative schools. 

Full but Careful Publicity 

It is suggested that gradings be made each year and that each 
year returns be given full and carefully planned publicity. Just 
what form this publicity should take is a matter to be decided 
later. Perhaps the wise decision will be, at the outset at least, to 
pubHsh in newspapers and magazines comparative standings, by 
states; but not to print details as to individual schools. Each 
school could then be sent a confidential report, showing its own 
standing. 

The publication of returns by states would have considerable 
news value, and it is probable that space could be secured in the 
leading newspaper of each city. The result would be a wave of 
popular interest in the local nursing schools which would be 
highly salutary. At the same time, however, the individual 
school would be protected from the storm of criticism sure to be 
leveled against it if its low standing were publicly known. 

Later, as the schools begin to show improvement, it might be 
well to announce that all schools having a grade above a certain 
level would be announced by name. Since the effectiveness of the 
whole grading plan depends in large measure upon the amount 
and type of publicity which is given the project, this question 
must be reviewed with care. 

Five Years of Grading 
In outlining the five-year program it is hoped to make each 
project contribute to the others. As the projects on Supply and 

33 



Demand and Job Analysis develop, it is expected that the details 
of the grading plan will become increasingly clear. 

The grading suggested for our program would lead to imme- 
diate results. The first grades would be reached in the fall of this 
coming year. They would cover as nearly as possible all the 
schools in the country, but would deal with only a few basic 
elements. Each year thereafter a similar grading would be pub- 
lished. The purpose of this work would be, not to set up a final 
standard list, but rather to stimulate all the schools towards 
improving their work, to educate the hospital trustees in their 
thinking about nursing education, and to awaken public interest 
to the need for supporting nursing schools. The grading would 
be not an end in itself, but rather a useful tool for securing 
improved conditions in the schools. As part of the work of grad- 
ing, there would also be gathered a large amount of supplementary 
information about what the schools are doing. This information 
would be published each year as soon as it could be gathered and 
digested. 

At the beginning of the fifth year, the Committee should have 
enough material at hand so that it can begin to formulate its final 
report. This monograph would be in three parts : first, the fifth 
gradings, together with a review of the progress made since the 
first gradings five years earlier; second, a statement of the basis 
for grading and the educational philosophy involved ; and third, a 
plan for a permanent grading committee, which should continue 
at regular, although perhaps not quite so frequent, intervals, the 
grading of schools of nursing. 

To Summarize 

This memorandum suggests that the work of the Committee on 
the Grading of Nursing Schools be considered as lasting for five 
years, with a total budget of approximately $200,000, and con- 
centrating upon three main projects. 

The first project would be a study of the supply and demand 
for nursing service. It would be carried on for two years, and 
would culminate with the publication of a monograph. The 
project would cost approximately $42,000. 

The second project — an analysis of the nature of good nursing 
service and how it can be supplied by nursing schools — would 
receive special attention in the third and fourth years, and would 

34 



lead to another monograph, at the end of the fourth year. The 
cost of this project would be approximately $72,000. 

The third project would be a study of existing facilities, and the 
actual grading of nursing schools. It would call for yearly reports 
and publications, each a trifle more elaborate than the preceding, 
and would end in the fifth year with concentrated study, and a 
final monograph report. The cost of the grading project would 
be about $86,000. 

The yearly output is planned about as follows : 

a. Within one year 

First grading — published study of comparative standings 

of all schools on a few basic points. 
Publication of additional statistical material showing 

what the schools are like. 
Publication of first returns on study of nursing shortage. 

b. Within two years 

Second gradings — showing progress schools have made 
since first gradings. 

Additional facts on school administration. 

Full study and printed monograph report on the problem 
of the nursing shortage, based upon the experience not 
only of nurses, but of doctors, hospital administrators, 
public health workers, and patients during the same 
period. Report to include studies of local experiments 
with hourly nursing, group nursing, and modernized 
registries. 

c. Within three years 

Third gradings — showing progress schools have made 

since first grading. 
Preliminary articles and pamphlets on problems of school 

administration. 

d. Within four years 

Fourth gradings — showing progress schools have made 

since first grading. 
Full study and printed monograph report or reports on 

(1) What nurses are being called upon to do after 

graduation, and how these demands will probably 
develop. 

(2) How nursing schools are actually run. 

(3) What effects existing administrative and teaching 

methods are having upon the growth of students. 

(4) What changes are probably needed to meet de- 

mands on the profession. 

(5) Typical problems faced by Boards of Trustees and 

Educational Committees; by Hospital Super- 
intendents; by Nursing School Superintendents; 

35 



and by Teachers and Supervisors; and methods 
successfully used for meeting them, 
e. Within five years 

Fifth gradings — in full monograph report, showing prog- 
ress over five years' interval ; with estimate of value of 
method, and plans for permanent grading body, if that 
seems desirable. 

Full summary of work of Grading Committee; its find- 
ings ; its resulting educational philosophy ; and its recom- 
mendations for the future. 



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